Doroh et al,. J Community Med Health Educ 2013, 3:4 DOI: 10.4172/2161-0711.1000216

Research Article Open Access

Volume 3 • Issue 4 • 1000216J Community Med Health EducISSN: 2161-0711 JCMHE, an open access journal

Determinants of Outpatient Services Utilization in Shiraz, 2012Vajihe Ramezani Doroh, Nahid Hatam, Abdosaleh Jafari, Shahnaz Kafashi and Zahra Kavosi*

School of Management and Medical Informatics, Shiraz University of Medical Sciences, Shiraz, Iran

*Corresponding author: Zahra Kavosi, School of Management and Medical Informatics, Shiraz University of Medical Sciences, Shiraz, Iran, Tel: +98-711-2340774; E-mail: zhr.kavosi@gmail.com

Received February 13, 2013; Accepted May 20, 2013; Published May 22, 2013

Citation: Doroh VR, Hatam N, Jafari A, Kafashi S, Kavosi Z (2013) Determinants of Outpatient Services Utilization in Shiraz, 2012. J Community Med Health Educ 3: 216. doi:10.4172/2161-0711.1000216

Copyright: © 2013 Doroh VR, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

IntroductionUtilization of healthcare services is an important determinant

of health [1-3], and has particular relevance as a public health and development issue in low income countries [4]. In fact, accessibility of healthcare services for the most vulnerable and underprivileged populations have been recommended by the World Health Organization as a basic primary healthcare concept [5]. It has been suggested that healthcare should be universally accessible without barriers based on affordability, physical accessibility, or acceptability of services [4,6]. Accordingly, increased use of health services is a major target in many developing countries [7]. The reasons that lead people to visit a doctor come from a complex interaction of different factors such as demographic, socioeconomic, and psychological aspects, morbidity profiles, and health services availability [2-5]. The effect and relative importance of each factor are affected by cultural background, health policies and health care system available. As lower socioeconomic groups have a higher burden of disease and therefore need more health services, equity is at the heart of the entire health care issue. There is limited information about how demographic, socioeconomic, health needs and other factors affect health service utilization in the country. The present study focused on these issues, and examined the determinants of outpatient visit within one month from the interview by examining incidence rate ratio.

MethodsThis was a cross-sectional household survey that was carried out

in Shiraz a city in Iran in 2012. Research location was Shiraz and the population included all the people above 18 and living in Shiraz. The Sample size determined by the current information regarding those seeking outpatient services was 1608. Sampling was done in four stages. First the municipality areas were considered as class and the sample size was determined in proportion with each class’s population. Then through the random sampling each of the areas were divided into ten residential blocks. Thirdly, the households were selected by the systematic sampling and finally the individuals were selected using KISH method [8].

The data needed were collected by a check list and a questionnaire. The check list measured the degree of the people utilization of the outpatient services and included the items as follows:

Demographic information, health insurance, income, employment

status, residential area, marital status, level of education and their utilization of the outpatient services during the previous month.

Questionnaire measuring life quality SF36: The questionnaire was used to measure the people’s health level. Questionnaire SF 36 has been adapted culturally by Montazeri et al. [9]. The questionnaire reliability was assessed and tested by the internal consistency statistical analysis and its validity was tested by the convergent validity method. The questionnaire measured 8 dimensions of health including physical performance, physical role, body aches, and perception of general health, life power, social performance and mental health. The maximum and minimum of each dimension were assigned 0 and 100 respectively. Life quality was classified into three levels: low (<50), medium (50-70), and high (>75).

We used zero inflated regression to identify the effects of various factors on utilization of out-patient services. Independent variables were gender, age, education, marital status, employment situation, insurance, income, health and region of residence. In each of these variables, we selected a reference group.

Dependent variable was utilization of out-patient services in previous month.

Results The findings showed that the mean utilization of the outpatient

services was 2.66 with a standard deviation of 3.07 and that the mean annual rate was 31.92. Of the outpatient services studied the highest mean (1.40) was related to pharmacy and the least (0.01) was related to that of emergency. Other descriptive results are shown table1.

AbstractIntroduction: Various factors such as the level of health, socio-economic, demographic, and health system

factors can affect on health service’s utilization. Identifying these factors and their importance can be used to reduce access barriers.

Method: 1608 individuals upper than 18 years-old in shiraz city 2012 selected to determine the factors affecting outpatient services utilization in a previous month. Zero Inflated regression n was used to examine the factors affecting utilization. The analysis was conducted using stata se 8 software.

Results: The variables of sex, health, education, region of residence, employment and insurance were related to outpatient services utilization during the past month women, noninsured individuals, employments utilized more than their reference group and individual with college education, better health status, areas number 2, 3 and 5 utilized less than of their reference group.

Conclusion: It seems that appropriate insurance coverage and development healthcare facilities of in other areas can improve utilization and equity.

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munity Medicine & Health Education

ISSN: 2161-0711

Community Medicine & Health Education

Citation: Doroh VR, Hatam N, Jafari A, Kafashi S, Kavosi Z (2013) Determinants of Outpatient Services Utilization in Shiraz, 2012. J Community Med Health Educ 3: 216. doi:10.4172/2161-0711.1000216

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Volume 3 • Issue 4 • 1000216J Community Med Health EducISSN: 2161-0711 JCMHE, an open access journal

Zero inflated regression showed that of the different variables studied the variables location, gender; self described health status, education level, insurance and employment could determine utilizing the outpatient services. Table 2 shows zero inflated regression results.

DiscussionThe mean annual rate of utilization was 31.92, more than those

found from the utilization study carried out in 2007 nationwide [10]. The difference could be attributed to the study time frame, study location, the study population as well as the differences in the demographic characteristics of the population studied. The highest mean of pharmacy utilization was according to Ebadifard et al. [11]. It seems that the accessibility to pharmacy services and the great numbers of OTC prescriptions as well as the high numbers of self-treatment, confirmed in the previous researches on the self-treatment behavior in Iran, could account for the increase in the number of people going to pharmacies.

The findings showed that mean frequency of utilizing the outpatient services for those inhabiting in the districts 2, 3 and 5 were less than those inhabiting in district 9. According to a study done by Monfared on the development of Shiraz districts, the municipality districts had undesirable health indexes during the study period [12]. May be the poor social and economic status of the districts caused a decrease in utilization of the services.

Our findings showed that gender affected the utilization of health services so that mean frequency of health services utilization among the women was more than the men. Most studies carried out in Iran and abroad, confirm the effect of gender on the utilization of health services. Albanse et al. [13], Valdivia [14], Lopez [15] and Schofield [16] in their studies showed that woman benefitted more health services than men of services including community centered services, doctors visits, preventive services, clinical visits, Anti - Parasite Drugs and outpatient services [13-16]. But Luo [17] in his study found no significant

relationship between the utilization of the outpatient services and gender. A number of reasons have been put for why the women had a higher rate of utilizing the outpatient services including their more attention to diseases occurrence and diseases early symptoms and their concerns for curing the illnesses through outpatient services while the men seek the medical services when their disease has reaches a critical stage [18].

The mean frequency of utilization from services in the non-insured was more. Liu [19] found that compared to those having no chronic illnesses those suffering from chronic diseases utilized between two to four times more outpatient services, though after corrections and adaptations the relationship hardly became significant (p=0.07) [19]. Lopez [15] and Szwarcwald [20] findings were opposite to our finding (14,20). Szwarcwald [20] showed the chance of utilization of those having private insurance was twice as much as those lacking this kind of insurance. But base on Luo [17] findings in general there was no significant relationship between utilizing outpatient services and the variable insurance, though the insurance coverage for both women and men in his study for the doctor’s visits was significant. Pourreza [21], Mohammad beigi [22] and Hosseinpoor [23] found no significant relationship between insurance and seeking clinical cares [21-23].

The main reason why those noninsured sought more services could be attributed to the fact that those lacking insurance could have poor health status.

Variables Number percent

Education

Under primary school 88 5.6

Primary school 107 6.8Guidance school 149 9.5

High school 520 33.2University 700 99.7

Marital statusMarried 923 58.9Widow 124 7.9

Celibate 517 33.1

GenderWoman 717 45.7

Man 851 54.3

InsuranceYes 1353 86.3No 214 13.7

Age18-34 836 53.335-65 644 41.165< 88 5.6

Income

Very Low 83 5.3Low 552 35.2

Medium 649 41.4High 185 11.8

Very High 99 6.3

HealthUndesirable 179 11.4

Medium 564 36Desirable 825 52.6

Table 1: Frequency of study variables.

Table 2: Factors related to utilization of outpatient services.

Variable SE sign IRR Lower UpperHealth 0.08 <0/001 0.994 0.99 0.1Age 0.001 0.422 0.999 0.1 1.21

Gender

Woman 0.06 <0.001 1.28 1.17 1.4Income 2.71 0.326 1 1 1

Marital Status

Widow 0.07 0.665 0.973 0.87 1.08Celibate 0.05 0.626 0.967 0.83 1.12

Insurance

Non 0.05 0.064 1.098 0.99 1.21

Education

Primary School 0.09 0.168 1.122 0.96 1.32Guidance School 0.07 0.103 0.872 0.74 1.03

High School 0.07 0.114 0.886 0.76 1.02University 0.07 0.028 0.833 0.71 0.98

Job

Employer 0.15 0.420 0.873 0.63 1.21Self-Employed 0.08 0.093 1.135 0.98 1.31

Employee 0.08 0.003 1.211 1.07 1.37Worker 0.11 0.501 0.925 0.73 1.16

Technical workers 0.11 0.68 0.953 0.76 1.19Housekeeper 0.067 0.415 1.053 0.93 1.19

Student 0.07 0.216 0.915 0.79 1.04

Region

1 0.08 0.350 1.076 0.92 1.252 0.06 0.004 0.797 0.68 0.933 0.06 <0.001 0.680 0.58 0.84 0.08 0.509 1.050 0.91 1.215 0.06 <0.001 0.631 0.51 0.776 0.08 0.270 1.088 0.94 1.267 0.09 0.796 1.023 0.84 1.228 0.08 0.138 0.866 0.72 1.05

Citation: Doroh VR, Hatam N, Jafari A, Kafashi S, Kavosi Z (2013) Determinants of Outpatient Services Utilization in Shiraz, 2012. J Community Med Health Educ 3: 216. doi:10.4172/2161-0711.1000216

Page 3 of 3

Volume 3 • Issue 4 • 1000216J Community Med Health EducISSN: 2161-0711 JCMHE, an open access journal

May be, we could claim that the health status as a main indicator of need to health services should be the determinant of the utilization. The current study findings showed that with an increase in the health level score the mean frequency of utilization was decreased. Various studies have corroborated the existence of a relationship between the health services utilization and the variable people health status. Also, Mohammmad Beigi [22] found a significant relationship between a need to hospitalization services and seeking the services [22]. Pourreza [21] too came to the conclusion that those that had assessed theirdisease malignancy medium compared to those that had assessed theirmalignancy slightly had four times more chance to be cured. The chancefor those assessing their disease very grave was doubled [21]. In a study,Schofield showed that the people with poor health status compared tothe people with good and very good health status were more eager tobenefit from general practitioners visits [16]. Luo [17] also came to theconclusion that the poor health status is related with more utilization ofclinical visits and hospitalization and non-hospitalization services [17].Also, Lopez [15] in his study found a positive significant relationshipbetween the reports of health complaints and the utilization oftreatment services. The mentioned relationship was confirmed aboutthe hospitalization services so that those suffering from one healthproblem had a chance of accessing equivalent to 1.16 and those havingtwo health problems had an accessibility chance of 1.68 to the treatmentservices [15].

Our findings showed that having an academic education level had caused a decrease in the mean frequency of the utilization of the services compared to the reference group, whose members had a preprimary school education level. According to a study carried out by Pourreza [21] there was a significant relationship between education level andseeking clinical cares so that those having a guidance school educationlevel compared to the others benefited less service [21]. According toa study done by Szwarcwald [20] the high levels of education, afteradaptations done to the variables, age and gender, had a significant effecton utilizing the services, a result contradicted by our findings [20]. thatthe people having academic education levels sought less services couldbe the two sides of the same coin., that is on the one hand these peoplepaid less attention to their health because they would not have enoughtime or on the other hand their self-treatment behavior decreased theirdemand for health services or may be these people paid more attentionto their health, so being healthier and needing less services.

Our findings showed that the mean frequency of services utilization in the employed people compared to the unemployed and invalids reference groups experienced an increase. Liu [19] too, in his study found a significant difference among the job groups in terms of benefitting the services so that the people having manual jobs or having dangerous jobs with low wages or salary benefitted more services [19]. That in our study the rate of utilization of the outpatient services was high could be attributed to the compulsory coverage of insurance among these people, so that having financial accessibility to the outpatient services. In addition, the high opportunity cost of the diseases in case of aggravating among the employed ones could have served as a motive to seek care for their diseases in the early stages of their illnesses.

ConclusionIn general, inequity in health system related to tow factors first

government role to decrease that whit insurance coverage and family physician and second living standards, people attitudes and beliefs that require cooperation other sector to reducing it.

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